by Lisa Amatangelo, MD, RVT, FACPh and Julie Cardoso, RDCS, RVT, RPhS

It is well known that there are gender differences that influence the medical profession, but are we aware of the gender inequities that continue to plague it? In these days of the “Time’s Up” and “#MeToo” movements, this issue has been pushed to the forefront of the national conversation. There is no better time than now to reinvigorate our discussions, spread awareness, generate solutions, and move closer to achieving gender equality for our profession.

The year 2017 marked a milestone in medicine. For the first time the number of women enrolling in U.S. medical schools exceeded the number of men.¹ Despite outnumbering men in medical school, women face persistent inequality when it comes to work and promotion. While there has been a tremendous increase in the number of female physicians in the workforce over the decades, women still only make up a little more than one third of the physician workforce.⁴

What’s concerning is women’s even greater underrepresentation at the upper echelons of medicine. Due mainly to a lack of promotion, academic leadership positions in medicine continue to be primarily filled by men. Only 22 percent of full professors and a mere 16 percent of medical school deans are women.²

Physicians also face one of the largest pay gaps that exist between the sexes among professionals. In 2016, an analysis of publicly reported salaries for more than 10,000 physicians found that male physicians earned nearly $20,000 per year more than those who are women.³

Interestingly, the disparity existed across all ranks, but varied considerably across specialties and institutions. Specialties such as orthopedic surgery, surgical subspecialties, OB/GYN and cardiology had the largest absolute sex differences in salary. In contrast, radiology, family medicine and emergency medicine had differences that were small and not statistically significant.³

The cost of inequality

Now that women make up the majority of students entering medical school, it is clear that women will soon represent a significant number of the best potential candidates for leadership positions in medicine. Indeed, medical societies and institutions realize the continued growth of their specialties rely on their ability to attract, retain and promote female physicians. Many are working to meet the demands and concerns of the changing medical workforce by providing more leadership training, grants and networking opportunities to women in addition to a bevy of other solutions.

Recruitment needs aside, it is well documented that businesses that have women on their boards have a better bottom line than those that don’t. “Women bring specific things to the table,” says Dr. Helane Fronek, Assistant Clinical Professor of Medicine, UC-San Diego School of Medicine and a Certified Physician Development Coach. “We are naturally more inclusive, collaborative, and are better communicators.” Fronek served as the first, and still the only, woman president of the American College of Phlebology. “I remember sitting in board meetings and wondering why everyone seemed to be focusing on a particular issue, when I felt that the real issue was something else,” she said. “It has been shown that companies make better decisions when they have varied points of view and approaches.”

On a global level, gender inequality does not only present a pressing moral and social issue, but also a critical economic challenge. When women— who account for half the world’s working age population—do not achieve their full economic potential, the global economy suffers. According to a recent McKinsey Global Institute report, if women were to participate in the economy identically to men, as much as $28 trillion could be added to the global annual GDP by 2025.⁴

Considering the costs of gender inequality, why does the gender gap exist? Why don’t women assume more leadership positions in medicine or earn as much as their male counterparts? As we approach these questions, many tend instinctively to raise the issue of gender discrimination. We should be careful to avoid the fallacy of false cause. Multivariate analyses have shown that gender discrimination is not the sole factor responsible for the gender gap. In order to comprehend the actual impact of gender discrimination, it is imperative to consider a host of alternative factors associated with gender as well.

Breadwinners versus caregivers

One key factor affecting the pay gap is childbirth. Wages are affected not only by the amount of work experience accumulated, but also by the continuity of the accumulation.⁵ Taking leave from a career due to childbirth—an act which instantly interrupts continuity in accumulation—is associated with reduced income. On average, mothers suffer around a 7 percent wage penalty per child.⁶

Following childbirth, there is the factor of child care. Even if one eliminates gender from the equation and focuses exclusively on women, research shows that mothers who maintain employment after childbirth have higher earnings than mothers who do not. The issue lies in the fact that women are twice as likely as men to take leave for child care, regardless of employment status. Furthermore, among those who took leave for child care, women stayed on leave more than three months longer than men.⁷

Beyond the pay gap, motherhood also impacts the number of women in leadership positions. Many women are reluctant to take on leadership roles because they fear the role will conflict with or limit the time needed for family responsibilities.

Anne Marie Slaughter famously wrote an article in The Atlantic about why women cannot have it all. As a Princeton Professor and Dean of Politics and International Affairs, as well as the former U.S. State Department Director of Policy Planning, she was not able to have it all either. In her article she points the finger at America’s social and business policies, rather than a woman’s level of ambition or something else, to explain the lack of women at the top. She states that these policies have led men to believe that their primary obligation is to be the breadwinner while at the same time, women have been led to believe that their primary obligation is to be the caregiver.⁸

Perhaps this is why in two-career households, women still take on more of the work at home. While men today are pitching in much more than past generations, the division of childcare and house work is still not equal.

Self and society

When presented with leadership opportunities, many women fall victim to negative self-perceptions. The imposter syndrome is known to affect women far more often than men. This is a psychological phenomenon in which people are unable to internalize their accomplishments, remaining convinced that they are frauds who do not deserve their success. Evidence of their competence is dismissed as luck, timing, or as a result of deceiving others.⁹

Many women also experience the stereotype threat, believing that they cannot succeed at historically male-dominated jobs. They also hesitate when it comes to negotiating because they do not view this as a behavior characteristic of women.

Unfortunately, instead of alleviating these negative self-perceptions, society tends to reinforce them. A study of self-advocating negotiators found that women are stuck in a catch-22 situation. “Assertive, self-advocating female negotiators suffer backlash consistent with negative masculine characterizations. They are seen as dominant and arrogant, and people do not want to interact on a peer level with them,” Amanatullah et al. said. “Non-assertive, other-advocating female negotiators suffer a different backlash consistent with negative feminine characterizations. They are seen as weak and gullible, and people do not want to be led by them.”¹⁰ Studies have also found the lack of role models and mentorship to be a reason why fewer female physicians are achieving key leadership positions.¹¹

“A lot of this comes down to the overall devaluing of feminine traits in medicine,” explains Fronek. “We each have both male traits (aggressiveness, directness, problem/solution-focus, competitiveness) and female traits (collaboration, receptivity, nurturing). Often, it is masculine traits that are rewarded more than feminine ones. It is ironic as we are in a caring-healing profession, where feminine traits are important—but not valued.” “The people who are put on a pedestal in medicine are those who rise in the ranks to leadership positions, those who publish the most, those who get the biggest grants, those who see the most patients, but the doctors that patients are most loyal to and appreciative of are the ones with the strongest feminine traits, in my opinion.”

Sexism and Sexual Harassment

At the institutional level, sexism is a serious issue. There is evidence of a “glass ceiling,” where women have difficulty advancing into the highest paying and most prestigious leadership positions due to a persistence of an “old boys club” mentality that promotes organizational cultures that favor men. Inversely, there is also evidence of a “sticky floor,” where women have difficulty advancing due to the allocation of fewer institutional resources and lower rates of promotion.¹²

At the individual level, sexual harassment poses an entirely different issue. Recently, the news has been overwhelmed with reports of celebrities committing heinous acts of sexual misconduct. While we may think our field is better than others given the ostensibly compassionate personalities that tend to pursue medicine, this is often not the case.

A recent survey of clinician-researchers conducted out of the University of Michigan found that 30 percent of women reported having experienced sexual harassment compared with only 4 percent of men. To compound the issue, women are discouraged from reporting these incidents. Dr. Reshma Jagsi, the author of the survey, explains that “women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse. Even in the #MeToo era, reporting such behavior is far from straightforward.”¹³

Closing the gap

Even though we have come far since the days of the Virginia Slims slogan, “You’ve come a long way, baby,” we still have a long way to go. In the face of our current issues, what can we do in order to close the gap?

Just as the causes of gender inequality are varied and nuanced, so are the solutions. We need to structure opportunities for women to have productive careers while meeting their personal goals by valuing the quality of work achieved over the quantity of hours worked. We need to reinforce positive self-perceptions by valuing feminine traits in the workplace and promoting female role models. We need initiatives at the individual, institutional, and national levels to increase leadership roles for women.

Particularly in the medical profession, we can achieve these goals by emulating the institutions that do a better job at advancing gender parity.

On the national level, generous maternity and paternity leaves in Scandinavia have been crucial to narrowing the gender gap. While our culture may be different from that of Scandinavia, the U.S. is beginning to see progress regarding paternity as well.

The State of America’s Fathers,” a MenCare Advocacy Publication from 2016, is the first-ever comprehensive report on U.S. fatherhood. It offers 140 pages of insight into how fatherhood today is different than ever before and the future of what is being called “The Fatherhood Revolution.”

In our opinion, one of the most important aspects to recognize is that changing conditions for women will require changing conditions for men. Men should be free to choose to be caregivers without encountering societal or professional stigma. We have a new generation of young men, our sons included, being raised by full-time working mothers. Let us hope that they understand, as we know our sons do, that supporting one’s family means more than earning an income. We can create a better society where all of us, men and women, can lead fulfilling lives taking care of our loved ones while simultaneously climbing the ladder of success.

How IR is priming women to lead

An article in the January 2018 issue of Endovascular Today reviewed the ways the IR field is working to bring more women into leadership, including the Society of Interventional Radiology’s (SIR’s) creation of the Women in IR (WIR) Section, and outreach efforts by SIR and the Cardiovascular and Radiological Society of Europe (CIRSE) that are intended to help women members to be more visible within the societies.

In addition, in 2015 SIR and CIRSE published a joint guideline regarding occupational radiation protection of pregnant or potentially pregnant workers in IR. The groups sought to allay women’s anxiety and work related stress created by a lack of accurate knowledge of the risks—a step geared toward removing some women’s perceived barrier to joining the profession and to deter potential discrimination and unnecessary constraints on pregnant women.¹⁵

It is expected as well that the new integrated IR/diagnostic radiology residency will attract more women to the field. The same was seen several years ago with the introduction of the vascular surgery 0+5 integrated track. Following this change, the percentage of women training in vascular surgery increased from 14 percent to 38 percent.¹⁶

References:

1. More Women Than Men Enrolled in U.S. Medical Schools in 2017. AAMC News Press Release, December 18, 2017.

2. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2015-2016. Association of American Medical Colleges.

3. Jena, MD, PhD, Anupam B., Olenski, BS, Andrew R., Blumenthal, MD, MBA, Daniel M. Sex Differences in Physician Salary in US Public Medical Schools, JAMA Int Medicine. 2016; 176(9):1294-1304.

4. McKinsey Global Institute, The Power of Parity: How Advancing Women’s Equality Can Add $12 Trillion to Global Growth, Executive Summary, September 2015.

5. CONSAD, Research Corporation. "An Analysis of the Reasons for the Disparity in Wages between Men and Women." U.S. Department of Labor, Employment Standards Administration, Jan. 2009.

6. Budig, Michelle J., and Paula England. "The Wage Penalty for Motherhood." American Sociological Review, vol. 66, no. 2, Apr. 2001, pp. 204-25.

7. Dey, Judy Goldberg, and Catherine Hill. "Behind the Pay Gap." AAUW Educational Foundation, Apr. 2007.

8. Slaughter, Anne-Marie. Why Women Still Can’t Have It All. The Atlantic, July/August Issue 2012.

9. Ballard, S, The Mismeasure of Women, Scientista, Spring 2011

10. Amanatullah, E.T., & Tinsley, C.H. (2013). Punishing female negotiators for asserting too much…or not enough: Exploring why advocacy moderates backlash against assertive female negotiators. Organizational Behavior and Human Decision Processes, 120(1), 110-122.

11. Zhuge Y, Kaufman J, Simeone DM, Chen H, Velazquez OC, Is There Still a Glass Ceiling For Women In Academic Surgery? Ann Surg, 2011 Apr;253(4):637-43.

12. Carnes M, Morrissey C, Geller S, Women’s Health and Women’s Leadership in Academic Medicine: Hitting the Same Glass Ceiling? J Women’s Health. 2008 Nov; 17(9): 1453-1462.

13. Jagsi, MD, D.Phil. et al. Sexual Harassment and Discrimination Experiences of Academic Medical Faculty, Research Letter, JAMA, May 17, 2016, Volume 315, Number 19.

14. Leigh Anne Dageforde, MD; Melina Kibbe, MD; Gretchen Purcell Jackson, MD, PhD. “Recruiting women to vascular surgery and other surgical specialties.” Journal of Vascular Surgery, Volume 57, Number 1 (2013), pp 262-267

15. L.T. Dauer, D.L. Miller, B. Schueler, J. Silberzweig, S. Balter, G. Bartal, et al. “Occupational radiation protection of pregnant or potentially pregnant workers in IR: a joint guideline of the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe” J Vasc Interv Radiol, 26 (2015), pp. 171-181

16. Association of American Medical Colleges. Table B3. Number of active residents, by type of medical school, GME specialty, and gender. https://www.aamc.org/data/448482/b3table.html. Accessed October 27, 2017.